A 3-level impaction technique for dorsal reshaping and reduction without dorsal soft tissue envelope dissection

Background: Preservation Rhinoplasty (PR) techniques are continuously evolving in the last two years. Many variations of old-fashioned techniques have been proposed since Daniel coined this term in 2018. Objectives: Authors want to describe indications for a new "three level impactions" technique allowing, in selected cases, a complete profile correction and dorsal reduction without the dorsal soft tissue envelope (STE) dissection. Methods: Three hundred fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race and technical details, surgical time and complications have been registered. Ninety-five dorsums were reduced and shaped without dissecting the dorsal soft tissue envelope, combining a 1) swinging door septoplasty with low septal strip resection, 2) endonasal bony cap mosaic osteotomies, and 3) Let down or Push down operation (LDO/PDO). Results: All patients showed a dramatic change in profile height and shape without neither dorsal STE dissection nor bony cartilage dorsal tissue resection. The average follow-up time was 14 months (range, 12-16 months). Conclusions: In selected patients, dorsum can be preserved without soft tissue envelope dissection. By combining multiple endonasal maneuvers is possible to obtain a dramatic change without dissecting the soft tissue envelope and at the same time avoiding any dorsal tissue resection: mosaic osteotomies for DKA conversion from S to V shaped dorsum, LDO and low septal strip resection for impaction and quadrangular cartilage flap rotation for profile setting. It is a versatile technique in selected patients, which leads to fast recovery and natural results.